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Contract Number <br />County <br />Rev 7-20-08 <br />EXECUTION OF CONTRACT <br />NON-COLLUSION AFFIDAVIT AND DEBARMENT CERTIFICATION <br />CORPORATION <br />The Contractor being duly sworn, solemnly swears (or affirms) that neither he, nor any official, agettt or employee has entered into any <br />agrcett-ettt, participated in any t~llusion, ~ otherwise taken any action which is in n~trairn of free competitive bidding in connection <br />with this Contract, and that the Contractor intends to do the worts with his own bonafide employees or subcattractors and did not bid for <br />the benefit of another cattractor. <br />By submitting this Faceattiat of Contracx, Nat-Collusion affidavit and Debarn~ent Certification, the Contractor is certifying his status <br />under penalty of perjury under the laws of the United Sues in acca'dance with the Debarttterit Certification attached, provided that the <br />Debamtent Certification also includes any required statements concerning exceptions that ate applicable. <br />SIGNATURE OF CONTRACTOR <br />/K <br />'y~l ~ ~jyV ST-2c.~G~T~d-~ <br /> <br />G, ~ <br />/Address as Prequali ~' <br />Attest /~' By _ <br />istarn Secretary reside i Presiderrt/Assistant Vice Resident <br />ect ctppropriote -itte Select appropriote title <br />Via'-ur4,~r ~.~ ~ ~ e~.tr~ -~tA~e~~ ~~ ~l <br />Rirn or type Signer's na Print or type Signer's natrre <br />CORPORATE SEAL <br />AFFIDAVIT MUST BE NOTARIZED <br />NOTARY SEAL <br />Subsertbeci and sworn to before me this the <br />day of ~P rn~u' 201._7 <br />``~~~ ~ ~ ~ LU C A $ ~ ~ ~ ~i~,~i <br />~i.. lc~~S -S~.~C ~.I,cCGc,S <br />Signature of Notary Public ~ ~ ~~~ <br />of, ~lc~G./1'L County :'~ ~~~ Z. <br />.. <br />~~ ~~~ <br />State of ~~ ~ ~i new- % ~ <br />~~ <br />~~,,)) 22 G ~ <br />My Commission Expires: ~ 7 ,[~~d ~~~~~G~'HAM,,,O ~` <br />7! <br />